Provider Demographics
NPI:1679661748
Name:BRYANT, LISA (APRN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BRYANT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 100174
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-3174
Mailing Address - Country:US
Mailing Address - Phone:864-646-7522
Mailing Address - Fax:864-646-3377
Practice Address - Street 1:16 ROBERTS BLVD
Practice Address - Street 2:
Practice Address - City:WILLIAMSTON
Practice Address - State:SC
Practice Address - Zip Code:29697-1136
Practice Address - Country:US
Practice Address - Phone:864-847-7323
Practice Address - Fax:864-847-7543
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN2781363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP1043Medicaid
SCAA12567108Medicare PIN
Q65091Medicare UPIN
SCNP1043Medicaid